APPLICATION FORM –ISVA

Please return your completed form to : or by post to SurvivorsUK, 1 Queen Anne Terrace, Sovereign Court, London E1W 3HH

NAME: / ADDRESS:
POST CODE:
Telephone Home: / Telephone Mobile:
Telephone Work: / NATIONALITY:
EMAIL ADDRESS:
Are you registered disabled? YES / NO
If so, what help would you need to attend an interview: / Which languages do you speak?

REFERENCES: Please provide details of 2 people who you have worked for in the last 3 years who know your workandwho would be willing to give you a reference [references will not be taken up until an offer is made]

NAME: / NAME:
ADDRESS: / ADDRESS:
Email address: / Email address:
TEL NO: m / TEL NO: m
RELATIONSHIP TO APPLICANT: m / RELATIONSHIP TO APPLICANT:
m
How long have you known them? / How long have you known them?
OCCUPATION: / OCCUPATION:

Have you at any time been convicted of a criminal offence? Or have you been restricted from working with children or vulnerable adults. If so, please refer to this in the Rehabilitation of Offenders form on the last page.

Do you havea current enhanced CRB check (within the last 3 months)? Yes/No

1. Previous & Current Employment (Paid or Voluntary)Please give most recent first

Employers Name & Address / Dates from/to / Brief Description of Job / Reason for Leaving

2. Education and Qualifications

Institution / Subject / Date from / Date to / Grade

3. Please tell us why you’re interested in taking up the Independent Sexual Violence Advisor role at SurvivorsUK and how you feel your experience and qualifications make you suitable for the role - refer to the role description and person specification and refer to these in your application. Please do not exceed two sides of A4.

Iconfirm that all the information I have given in this application form is correct.

Signed………………………………………………………………………………………………………….. Date …………………………………….……………………………

Equal Opportunities Monitoring Form

CONFIDENTIAL

You are requested to complete and return this form in order to enable Survivors UK to monitor its equal opportunities policy and ensure that any barriers to employment are identified and removed.

This information will be detached from your application form prior to the selection process and remain confidential.

Please tick or complete the boxes that apply to you and self-define or add any other information if you wish.

1. Are you: Male [ ] Female [ ]2. Date of Birth:

3. How would you describe your ethnic origin?

Bangladeshi [ ] Black African [ ] Black-Caribbean [ ] Black Other [ ]

Chinese [ ] Indian [ ] Pakistani [ ] White [ ] Other [ ]

Please provide further details if you wish______

4. Do you consider yourself disabled?Yes [ ] No [ ]

5. Are you currently in paid work?Yes [ ] No [ ]

6. Where you did first see this post advertised?______

Rehabilitation of Offenders Act

CONFIDENTIAL

This post involves working with adult men who may be vulnerable. Although this post is not exempt from the Rehabilitation of Offenders Act 1974, we ask that you reveal all criminal convictions, spent or otherwise and advise that a police check will be conducted if you are offered the post. This means that we would like you to tell us about all convictions even if they were a long time ago.

This information will be treated in the strictest confidence.

Please tick as appropriate:

[ ] I have no convictions

[ ] I have the following convictions as detailed below

Date / Offence / Conviction

I confirm that all the information I have given in this application form is correct.

Signed______

Date______

Print name______

Please return to:

1 Queen Anne Terrace, Sovereign Court, The Highway, London, E1W 3HH

Updated 30.01.15JQ Page 1 of 6